2.0 Analysis 2.1 Introduction As there is little margin for error while piloting outbound Prince Rupert Harbour using the channel north of the Kinahan Islands, particularly in bad weather, it is essential that effective bridge resource management (BRM) be practised. 2.2 Situational Awareness and Information Processing Situational awareness can be defined as all the knowledge that is accessible and can be integrated into a coherent picture, when required, to assess and cope with a situation. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information, such as location, speed, and the presence of hazards. A marine pilot has to maintain situational awareness to maintain safe control of the ship. When performing tasks with which they are familiar, persons know the normal flow of activities and action alternatives and, therefore, do not always consult the complete set of defining attributes before acting in a familiar situation. There is a natural tendency to refrain from using all the cues available. Instead, a person who expects certain cues will use those cues to quickly confirm his/her assessment of the situation and take what is apparently appropriate action without referring to other information which may corroborate or conflict with the evaluation. When persons are stressed by, for example, the difficulty of a situation or pressures for on-time performance, there is a tendency for their attention to become even more narrowed so that even those cues which are present are missed, ignored or discounted. Stress can also affect the perception of time. Under stressful conditions, people overestimate the amount of time which has passed. The pilot reported that he could not see any lights except Ridley Terminals as a faint glow when south-west of Barrett Rock. However, Prince Rupert Grain Terminal was closer, lighted, and also had a vessel alongside. It is therefore probable that he misidentified the origin of the faint glow in the reduced visibility. This would account for altering course too soon and for his assumption that the green flashing buoy to port was Ridley Island buoy instead of Georgia Rock buoy. When a course of 250, from an alter-course position off Prince Rupert Grain Terminal, is laid off on the chart, the course line runs through the vicinity of Kestrel Rock. However, the pilot believed that the vessel was abeam of Ridley Terminals, some five cables ahead, and the same course of 250 laid off from that area would bring Georgia Rock buoy ahead, as the pilot had intended. The pilot lost his situational awareness in that he misidentified two buoys located 1.3 miles apart, most probably as a consequence of confusing the loom of the terminal lights. The belief that the vessel was about five cables ahead of her actual position also indicates that the pilot had over-estimated the passage of time. Several factors could have contributed to the pilot's over-estimating the passage of time: the poor visibility, the pilot's late arrival on board due to a delayed flight, his concerns about disembarking in rough sea conditions or being carried on to the next port of call should it have been impossible to disembark, and his concerns about the next morning's assignment. All of the foregoing could have produced enough stress or pressure to narrow the pilot's attention and distort his perception of time passing. 2.3 Bridge Resource Management (BRM) The concept of BRM is to emphasize teamwork to optimize the use of all available resources, including equipment, written information, procedures, and personnel, to foster effective decision making during critical phases of a passage. Had BRM been practised, courses would have been laid off on the chart with the times of course alterations. The vessel's progress could have been closely monitored throughout by the bridge team and the 2042 position brought to the pilot's attention. Additionally, had either the OOW or the pilot laid off the course of 250 (T) from the position of 2042, it would have been apparent that the vessel was heading directly toward Kestrel Rock. As it was, the bridge team testified that it was not aware that the pilot was having difficulty in determining the vessel's position or in sighting and identifying the lighted buoys. Both the master and the OOW, individually, had identified Georgia Rock buoy and East Kinahan Island light and assumed that the pilot had also done so. The OOW had also visually identified Ridley Island buoy. Had the principles of BRM and good seamanship been observed, the sighting of these lights would have been reported as part of a free flow of information. Mariners have confidence in the knowledge and skills of marine pilots. The common or normal procedure is for masters and ship officers to trust a pilot and to stay out of his way. There is a reluctance to do anything which may be considered a distraction for or interference with a pilot, which is exactly what took place on the bridge of the TRANS ASPIRATION, where he was trusted implicitly. To gain a pilot's perspective of ship's crew/pilot interaction, representatives of the Pacific Pilotage Authority and British Columbia Coast Pilots Limited cited examples of ships calling at British Columbia ports with unqualified and unskilled officers and crew, language problems, and poor attitudes. These attributes were considered as being partly the reason for the lack of communication between pilots and crew in general. Although none of these factors are relevant to the TRANS ASPIRATION, pilots become conditioned to these circumstances. 2.4 Navigational Aids 2.4.1 Radars Because the vessel's radars were later found to be operating normally, the reason the radar PPI screens flooded with sea clutter while the pilot attempted to retune the radars was most likely that the tuning controls were not operated as designed. The fact that the PPI screens were blank and the panel lights were still on could be attributed to the brilliance control being inadvertently turned full off. Furthermore, with the sets in question, when the rain clutter control is turned full on, the screen appears blank except for the trace of the heading marker, which may be very dim, depending on the amount of brilliance applied. Alternatively, a temporary power blackout would result in the picture being lost until the sets warmed up again, but the panel lights would come back on instantly. The engineers reported no such blackout. The pilot had not taken the ARPA training course. He was familiar with the sets in question; however, pilots use many different types of radars in the course of their job. 2.4.2 Satellite Navigator and Loran C Because the navigation watch experienced no difficulty in obtaining a position, they were unaware that the pilot had assumed that the vessel was five cables ahead of her actual position. Had the watch known of the pilot's assumption, the position on the chart could have been brought to the pilot's attention and checked by a position obtained from either the operational satellite navigator or Loran C. 2.4.3 Course Recorder The course recorder trace is not consistent with the pilot's account of course alterations; for example, the trace indicates that the vessel swung from a heading of 190 (G) to a heading of 250 (G) just before the grounding in approximately two minutes with no real indication of slowing the swing as reported by the pilot. 2.5 Seamanship Good seamanship would dictate that headway should have been reduced or all way taken off the vessel until such time as the position could be ascertained. 3.0 Conclusions 3.1 Findings The adverse weather conditions and the anticipated rough seas at Triple Island were the deciding factors in determining the vessel's route. The vessel was travelling at a speed not adapted to the prevailing circumstances and visibility. The pilot, although uncertain of the vessel's position, did not share his uncertainties with the navigation watch. Both Georgia Rock buoy and Ridley Island buoy have the same light characteristics. The pilot mistook Georgia Rock buoy for Ridley Island buoy and made a bold and premature alteration of course. The navigation watch had plotted the position of the vessel by radar but did not bring it to the pilot's attention. The navigation watch had sighted navigational aids for which the pilot was searching but did not convey this information to the pilot. The navigation watch reported that the radars were operating satisfactorily at all times. The pilot reported that the radars he was using were not operating satisfactorily and that he was unsuccessful in retuning them. Although there was a mooring party on the forecastle, no dedicated look-out was assigned forward. 3.2 Causes The TRANS ASPIRATION grounded on Kestrel Rock because the vessel's position was not established by the pilot before a critical course alteration, and the vessel's speed was not adapted to the prevailing circumstances and visibility. A contributing factor was the lack of exchange of information between the bridge team and the pilot. 4.0 Safety Action 4.1 Action Taken 4.1.1 Light Characteristics In January 1995, as a result of a cyclical review process of navigational aids, the Canadian Coast Guard (CCG) decided to change the light characteristics of Georgia Rock buoy (D43) to quick-flashing green (QG), CHS Chart No. 3958 refers. 4.1.2 Pilot Passage Planning In two 1991 occurrences (TSB Report Nos. M91L3015 and M91L3012), the Board found that the involved vessels had left the navigation channel when the pilots had prematurely made the usual alteration of course. Neither the pilot nor the officer of the watch had recognized that the vessel was not on the intended course before the course change. These navigation errors could have been detected if passage planning had been in place and the progress of the vessel had been monitored by the bridge team. As a result, the Board recommended that: The Department of Transport require that the pilotage authorities publish official passage plans for compulsory pilotage waters and make them available to masters to facilitate monitoring of the pilot's actions by the vessel's bridge team. In response, the Department of Transport stated that the Pilotage Actdid not provide for the Department of Transport to require pilotage authorities to take action of the nature recommended. The Pacific Pilotage Authority also did not agree with passage plans; it expressed concern that there would be a question of liability, both for the pilot and for the Authority, should a ship following that plan become involved in an accident. However, supported in part by the circumstances of this occurrence, the Board still felt that close monitoring of a vessel's progress in accordance with an agreed passage plan would enhance the safe conduct of a vessel. As such, in its Safety Study of the Operational Relationship Between Ship Masters/Watchkeeping Officers and Marine Pilots, the Board recently recommended that: The Department of Transport require that pilots, as part of their initial hand-over briefing: obtain the master's agreement to the intended passage plan; and invite the bridge team's support by having the officer of the watch plot and monitor the vessel's position at regular intervals and report the position to the pilot with respect to the agreed passage plan.